Safety of Embolic Materials

Abstract

To Fuse or Not to Fuse? To THE EDITOR: I read with interest the article on internal fixation of the lumbar spine by Dickman, et al. (Dickman CA, Fessler RG, MacMillan M, et al: Transpedicular screw-rod fixation of the lumbar spine: operative technique and outcome in 104 cases. J Neurosurg 77:860-870, December, 1992). I wish to commend the authors for an interesting piece of work. However, this article is just another "how we do it and our results" paper and I submit that this retrospectively retrieved information adds very little to the totally inadequate literature existing to date on lumbar spine fusion.Technology continues to offer better methods of catalyzing a desired result, but we have failed to respond to the most pertinent question that has remained unanswered for decades: "What are the indications for lumbar spine fusion?" A recent review of the literature by Turner, et at., I reinforces this question and suggests that few real guidelines currently exist. They state, "No advantage has been demonstrated for surgery with fusion over surgery without fusion for several low back disorders, and the complications of fusion are common." The role of lumbar fusion needs to be defined for specific lumbar disorders with prospective randomized trials. When this is accomplished, the time, expense, and added morbidity associated with this technology will be justified to our patients and our peers. 1. Turner JA, Ersek M, Herron L, et aI: Patient outcomes after spinal fusions. JAMA 268:907-911. 1992RESPONSE: We appreciate Dr. Atkinson's interest in our manuscript. He is 100% correct that one of the most important unanswered questions regarding lumbar fusions is "what are the indications?" At this time, we have relatively good data for these indications in trauma.' In addition, prospective randomized evaluations have clearly answered this question for intervertebral disc disease. 2 Similar data exist for spondylolisthesis. 1 However, degenerative disease of the spine remains an area in which we have very few answers. The breadth and complexity of disease processes which are encompassed under the title "degenerative disease" makes the establishment of definitive indications for fusion an extremely difficult question to answer. Nonetheless, prospective randomized trials that will address these questions are currently being established.In the meantime, we are left with a retrospective analysis of our own results. At this time, analysis of large case loads of lumbar fusions utilizing instrumentation for augmentation of the fusion rate is relatively sparse in the neurosurgical literature. Neurosurgeons J. Neurosurg. / Volume 79/ July, 1993 have been, and remain, leaders in the field of spinal surgery, and it is imperative that we critically analyze our operative results and discuss new techniques. Our paper was not intended to address specific indications for fusion. It was intended to: 1) educate the neurosurgical community regarding the surgical techniques for pedicle screw fixation; 2) review the operative anatomy, morp...